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The time is now to act on inequalities

17 Mar 2017

PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR, PUBLIC HEALTH, UNIVERSITY OF SYDNEY

An appropriate response from Australia and its new Health Minister to the health problems our country is confronting would start with a goal-based strategic approach to inequality and the injustice and health disadvantage that travels with it.

Many social and political analysts agree that inequality has manifested itself as an immense force in recent elections, including the vote on Brexit and the elevation of Donald Trump. The core temperature in the social volcano reached a critical level as workers' wages froze while top executives received ever more millions. Now the volcano has erupted. A period of prolonged social unrest and loss of confidence in political structures is predicted.

At the World Economic Forum in Davos, Switzerland last month, inequality received unusual attention. The Forum is traditionally for high-flying business magnates, princes of the financial world and others who have benefited immensely from recent decades of global economic progress. But this year the glitterati, as they checked their ski bindings, nervously added inequality to their agenda. Inequality they ranked as “the most important trend likely to determine development across the world over the next decade”.

Now inequality may seem remote from us, our patients and the health of our communities but it may be closer than we think. Life expectancy and quality of health and life depend on life opportunities being relatively equal. Inequality is a powerful risk factor and as UK (nee Australian) epidemiologist Michael Marmot has shown and spoken forcefully in his 2016 ABC Boyer Lectures, can outweigh even smoking as a damage to health.

Hear the rumble in the mountain and be afraid

Voices urging health professionals to heed the rumbles deep in the mountain include those of Marmot and Flinders University's Professor Fran Baum. And thank goodness that to an extent we have done so. The Aussie “fair go” has contained the avarice of economic fundamentalists who would turn the torch of unfettered market forces on everything. And so Australia retains Medicare, public education and social welfare programs that mitigate potential catastrophes and life-long loss of opportunity. With the exception of Indigenous health, our social gradients in life expectancy are not savage although far from top drawer compared, say, with Scandinavia.

What to do?

We can analyse the statistics and note the extent of inequality and its effects, but it is quite another to work out what we might do about it.

A recent article in the BMJ by Kate E Pickett and Richard G Wilkinson, epidemiologists at York University, reflected on the agitation on the Davos ski slopes. Inequality, they observed, “during the 20th century in most rich countries fell almost continuously from the 1930s to the 1970s but then increased dramatically from the 1980s”.

So presumably the deeply troubling levels of inequality that are driving current unrest can be undone. As John Kennedy observed, man-made problems are generally amenable to man-made solutions.

Pickett and Wilkinson remind us that the late Tony Atkinson, an economist and activist who spent his lifetime concerned about inequality, identified several actions relating to taxation and minimum wages that he calculated could help. So good minds have been at work.

Marmot has written extensively on what might be done about inequalities. His reports, built on a strong base of evidence, focus on six areas for action:

Give every child the best start in life;

Enable all children, young people and adults to maximise their capabilities and have control over their lives;

Create fair employment and good work for all;

Ensure healthy standard of living for all;

Create and develop healthy and sustainable places and communities; and

Strengthen the role and impact of ill-health prevention.

“Delivering these policy objectives,” he writes, “will require action by central and local government, the [national health authority], and the private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies.”

Conceivably many of us can do a bit about several of these goals. A big challenge demands a big response and an imaginative and creative political push. It’s ages since we had a national health policy that made you stop and think with its depth and challenge. Let’s help make it happen.